Healthcare Provider Details

I. General information

NPI: 1639982671
Provider Name (Legal Business Name): LUCIENNA MARIA WOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 NASH WAY
SAINT LOUIS MO
63110-1020
US

IV. Provider business mailing address

4590 NASH WAY MAILSTOP: 90-29-928
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 773-816-3542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2026025320
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: